Exam Application

I. Personal Information

First Name:

MI:

Last Name:

Phone:

Date of Birth:

SSN:

Verify SSN:

Email:

Verify Email:

Current Mailing Address

Address: Address 2:

City:

State/Province:

Zip / Postal Code:

Country:

Candidate Photo

The photo must be recent, and of passport quality.
All photos will be reviewed by CRDTS and may be rejected if they are not found be acceptable for identification purposes. If determined to be unacceptable you will be notified by email and asked to upload a replacement photo.
Photos must be in one of the following formats: JPG/JPEG, GIF, or PNG
Photos must be square and have a minimal resolution of 200x200 and max resolution of 500x500
Photo may be black & white OR color
(click image to edit)

Exam Type

Dental

Dental Hygiene

Restorative Auxiliary

Both Dental Hygiene and Restorative Auxiliary

Therapist

Anesthesia

I am a Junior Student of Record at an accredited dental school participating in the CRDTS Curriculum Integrated Format dental examination (Must furnish an original copy of the Letter of Certification for the Integrated Format Examination - Junior Student of Record).

I am a Senior Student of Record at an accredited dental school participating in the CRDTS Curriculum Integrated Format dental examination. (Must furnish an original copy of the Letter of Certification for the Integrated Format Examination - Senior Student of Record).

I am a Resident or Graduate Student of Record at a dental school participating in the CRDTS Curriculum Integrated Format dental examination and have graduated from a program accredited by the ADA Commission on Dental accreditation OR enrolled in an accredited program that leads to a DDS/DMD. (Must furnish an original copy of the Letter of Certification for the Integrated Format Examination - Resident or Graduate Student of Record).

I hold a diploma from an accredited dental school. (Must furnish a notarized copy of the diploma by the deadline date for the exam).

I will have successfully completed a prescribed course of study in an accredited dental school within 90 days after the examination date. (Must furnish an original copy of the Letter of Certification for the Dental Traditional Format Examination).

I hold a diploma from a non-accredited dental school. (Must furnish verification from the State Dental board of a state that accepts the results of the CRDTS examination indicating that you are eligible for licensure in the state upon successful completion of the CRDTS examination. In addition, a copy of your diploma with an English Translation MUST be provided).

III. Insurance Application

Please provide details for any "YES" answer. A Student Dental Board Coverage Application (see Candidate Forms) must be submitted.
A. Have you ever been treated for alcoholism, narcotic addiction or mental illness? Yes No
B. Have you ever been charged or convicted of a felony? Yes No
If yes, please give any details:
C. Have you ever had any chronic illness or physical defect? Yes No
D. Have any claims or suits ever been filed against you as a result of professional Service rendered? Yes No
If yes, please give any details, amounts paid, dates:
E. Has this form of insurance or other similar insurance ever been cancelled, refused or nonrenewed? Yes No
If yes, please give reason:

IV. School of Graduation

School of Graduation:

Year:

Other School: Graduation Date (MO/DAY/YR): Additional Considerations:

Request Left Handed Unit:

V. Examination Schedules

Are you retaking this examination?

Yes

No

Are you taking this examination for remediation?

Yes

No

Please select which examination parts you will be taking:

Part I. - DCTP Written Exam

Manikin Sections:

Part II. - Endodontics Exam

Part III. - Fixed Prosthodontics Exam

Part IV. - Periodontal Exam

Part V. - Restorative Exam

Patient Sections:

Part IV. - Periodontal Exam

Part V. - Restorative Exam

VI. Examination Dates

Integrated Examinations - Open to Students of Record ONLY
Traditional and Retake Examinations (Parts II-V) - Open to ALL Candidates

VII. Previous Examination Information

If you have taken the CRDTS Dental Exam previously, or a clinical Dental Exam with another agency, please indicate the agency, site(s) and exam date(s) (MM/YY)

Previous Examination Clinical Sites(s)

Testing Agency

Previous Exam (Date - MM/YY)

VIII. Limitation of Liability Agreement

1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
3. Auxiliary Personnel: Use of Assistants. Auxiliary personnel are not permitted to assist at chairside during the manikin examinations. Auxiliary personnel are permitted to assist at chairside during periodontal and restorative examinations. Dentists, dental hygienists and dental therapists(any graduate, licensed or unlicensed), final year dental, dental hygiene or dental therapy students may not act as chairside assistants during the restorative and periodontal examinations.
4. Limitation of Liability, Assumption of Risk, and Indemnity.

A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.

5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.

IX. Candidate Signature

By checking this box the applicant acknowledges that s/he has read and understood this Application and the Dental Candidate Manual and agrees to abide by all terms and conditions contained therein.

I hereby state that I have read and understand Section V above: Disclosure, Limitation of Liability and Indemnity Agreement and agree to its terms

I have read and agree to the Hold Harmless Agreement (link) for the simulated examination

These electronic signatures are legally binding and have the full validity and meaning as the applicant’s handwritten signature.

Electronic Signature

Date

Prev Page Complete

II. Exam Type Preference

Please select whether you want to take the patient based or simulated patient based exam.

Select Exam Type:

Patient

Simulated Patient (Manikin)

Select Mandibular Quadrant:

Right Mandibular Quadrant

Left Mandibular Quadrant

III. Retake Examination

Are you retaking this examination?

Yes

No

Are you taking this examination for remediation?

Yes

No

IV. Certification

I hold a diploma from an accredited dental hygiene school. (Must furnish a notarized copy of the diploma by the deadline date for the exam).

I will have successfully completed a prescribed course of study in an accredited dental hygiene school within 60 days after the examination date. (Must furnish an original copy of the Letter of Certification for the Dental Hygiene Examination. I understand that my school may submit my name on a 'blanket' letter on official letterhead, along with other candidates from my school, verifying that I have met or am expected to meet all the requirements for graduation.)

I hold a diploma from a non-accredited dental hygiene school. (must furnish verification from the State Dental board of a state that accepts the results of the CRDTS examination indicating that you are eligible for licensure in that state upon successful completion of the CRDTS examination. in addition, a copy of your diploma with an English Translation MUST be provided).

V. School of Graduation

School of Graduation:

Year:

Other School: Graduation Date (MO/DAY/YR):

Administering Local Anesthesia

I am trained to Administer Local Anesthesia:

Yes

No

If yes, please select one of the options below:

The course I took was administered within the CRDTS Region. I understand that I must submit a certificate from that course, verifying I have had the appropriate educational and clinical training to administer local anesthesia at the examination site. I also understand that if I am a recent graduate from one of the accredited dental hygiene schools within the CRDTS Region, or I am soon to graduate, my school may submit my name on a 'blanket' letter on official letterhead, along with other graduates, verifying my training.

I am not a present graduate or attending a school within the CRDTS Region. I must submit a certificate, or letter from my school or course on official letterhead verifying that I have had the appropriate educational and clinical training to administer local anesthesia at the examination site.

* I understand that if I am unable to provide 'proof' of completion of a board approved course at the time I make application, I will not be allowed to administer local anesthesia at the examination site.

Additional Considerations:

Request Left Handed Unit:

VI. Examination Dates

Please select three choices in chronological order.

VII. Previous Examination Information

If you have taken the CRDTS Dental Hygiene Exam previously, or a clinical Dental Hygiene Exam with another agency, please indicate the agency, site(s) and exam date(s) (MM/YY).

Previous Examination Clinical Sites(s)

Testing Agency

Previous Exam (Date - MM/YY)

VIII. Limitation of Liability Agreement

1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
3. Patients. As part of the examination, you must perform certain types of clinical procedures on patients. Patients must sign a "Treatment Consent Form" prior to any procedure.
4. Limitation of Liability, Assumption of Risk, and Indemnity.

A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.

5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.

IX. Candidate Signature

By checking this box the applicant acknowledges that s/he has read and understood the following and agrees to abide by all terms and conditions contained therein.
1. Application
2. Dental Hygiene Candidate Manual
3. Online Dental Hygiene Candidate Orientation

I hereby state that I have read and understand Section V above: Disclosure, Limitation of Liability and Indemnity Agreement and agree to its terms.

I have read and agree to the Hold Harmless Agreement (link) for the simulated examination

These electronic signatures are legally binding and have the full validity and meaning as the applicant’s handwritten signature.

Electronic Signature

Date

Prev Page Complete

II. School of Graduation

School of Graduation:

Year:

Other School: Graduation Date (MO/DAY/YR): Continuing Education Course

State:

Year:

Title:

Administrator:

Additional Considerations: Request Left Handed Unit:

III. Restorative Training Verification

I am trained to perform Restorative Procedures:

Yes

No

If yes, please select one of the options below:

I hold a certificate from an approved program for the state in which I am applying for licensure. I have verified that results from the CRDTS Restorative Auxiliary Examination are accepted for licensure in that state. I understand that I must submit a certificate from same course, verifying I have had the appropriate educational and clinical training to perform the restorative procedures at the examination site. I also understand that if I am a recent graduate from one of the accredited dental hygiene schools or a state approved dental assisting program or course within the CRDTS Region, or I am soon to graduate or become certified, my school may submit my name on a 'blanket' letter on official letterhead, along with other graduates, verifying my training.

I am not a current graduate or attending a school or program/course within the CRDTS Region. I must submit a certificate, or letter from my school or course on official letterhead verifying that I have had the appropriate educational and clinical training to perform the restorative procedures at the examination site.

IV. Retake Examination

Are you retaking this examination?

Yes

No

V. Examination Dates

VI. Previous Examination Information

If you have taken the CRDTS Restorative Auxiliary Exam previously, or a Restorative Exam for Auxiliaries with another agency, please indicate the agency, site(s) and exam date(s) (MM/YY).

Previous Examination Clinical Sites(s)

Testing Agency

Previous Exam (Date - MM/YY)

VII. Limitation of Liability Agreement

1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
3. Patients. As part of the examination, you must perform certain types of clinical procedures on patients. Patients must sign a "Treatment Consent Form" prior to any procedure.
4. Limitation of Liability, Assumption of Risk, and Indemnity.

A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.

5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.

VIII. Candidate Signature

By checking this box the applicant acknowledges that s/he has read and understood the following and agrees to abide by all terms and conditions contained therein.
1. Application
2. Restorative Auxiliary Candidate manual

I hereby state that I have read and understand Section V above: Disclosure, Limitation of Liability and Indemnity Agreement and agree to its terms.

These electronic signatures are legally binding and have the full validity and meaning as the applicant’s handwritten signature.

Electronic Signature

Date

Prev Page Complete

V. Dental Hygiene - Retake Examination

Are you retaking this examination?

Yes

No

V. Dental Hygiene - Exam Type Preference

Please select whether you want to take the patient based or simulated patient based exam.

Select Exam Type:

Patient

Simulated Patient (Manikin)

Select Mandibular Quadrant:

Right Mandibular Quadrant

Left Mandibular Quadrant

VII. Dental Hygiene - Examination Dates

Please select three choices in chronological order.

VIII. Dental Hygiene - Previous Examination Information

If you have taken the CRDTS Dental Hygiene Exam previously, or a clinical Dental Hygiene Exam with another agency, please indicate the agency, site(s) and exam date(s) (MM/YY).

Previous Examination Clinical Sites(s)

Testing Agency

Previous Exam (Date - MM/YY)

Prev Page Next Page

IX. Restorative Auxiliary - Retake Examination

Are you retaking this examination?

Yes

No

X. Restorative Auxiliary - Examination Dates

XI. Restorative Auxiliary - Previous Examination Information

If you have taken the CRDTS Restorative Auxiliary Exam previously, or a Restorative Exam for Auxiliaries with another agency, please indicate the agency, site(s) and exam date(s) (MM/YY).

Previous Examination Clinical Sites(s)

Testing Agency

Previous Exam (Date - MM/YY)

Prev Page Next Page

XII. Limitation of Liability Agreement

1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
3. Patients. As part of the examination, you must perform certain types of clinical procedures on patients. Patients must sign a "Treatment Consent Form" prior to any procedure.
4. Limitation of Liability, Assumption of Risk, and Indemnity.

A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.

5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.

XIII. Candidate Signature

By checking this box the applicant acknowledges that s/he has read and understood the following and agrees to abide by all terms and conditions contained therein.
1. Application
2. Restorative Auxiliary Candidate Manual 3. Dental Hygiene Candidate Manual
4. Online Dental Hygiene Candidate Orientation

I hereby state that I have read and understand Section V above: Disclosure, Limitation of Liability and Indemnity Agreement and agree to its terms.

I have read and agree to the Hold Harmless Agreement (link) for the simulated examination

These electronic signatures are legally binding and have the full validity and meaning as the applicant’s handwritten signature.

Electronic Signature

Date

Prev Page Complete

II. Certification

I hold a diploma from an accredited dental therapist program. (Must furnish a notarized copy of the diploma by the deadline date for the exam).

I will have successfully completed a prescribed course of study in an accredited dental therapist program within 90 days after the examination date. (Must furnish an original copy of the Letter of Certification for the Dental Therapy Examination).

III. School of Graduation

School of Graduation:

Year:

Other School: Graduation Date (MO/DAY/YR): Additional Considerations: Request Left Handed Unit:

IV. Retake Examination

Are you retaking this examination?

Yes

No

If so, please indicate which part(s):

Manikin-Based Exam:

Patient-Based Exam:

V. Examination Dates

Traditional and Retake Examinations (Parts II-V) - Open to ALL Candidates

VI. Previous Examination Information

If you have taken the CRDTS Dental Therapist Exam previously, or a clinical Dental Therapist Exam with another agency, please indicate the agency, site(s) and exam date(s) (MM/YY).

Previous Examination Clinical Sites(s)

Testing Agency

Previous Exam (Date - MM/YY)

VII. Limitation of Liability Agreement

1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
3. Auxiliary Personnel: Use of Assistants. Auxiliary personnel are not permitted to assist at chairside during the manikin examinations. Auxiliary personnel are permitted to assist at chairside during periodontal and restorative examinations. Dentists, dental hygienists and dental therapists(any graduate, licensed or unlicensed), final year dental, dental hygiene or dental therapy students may not act as chairside assistants during the restorative and periodontal examinations.
4. Limitation of Liability, Assumption of Risk, and Indemnity.

A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.

5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.

VIII. Candidate Signature

By checking this box the applicant acknowledges that s/he has read and understood this Application and the Dental Therapist Candidate Manual and agrees to abide by all terms and conditions contained therein.

I hereby state that I have read and understand Section V above: Disclosure, Limitation of Liability and Indemnity Agreement and agree to its terms.

These electronic signatures are legally binding and have the full validity and meaning as the applicant’s handwritten signature.

Electronic Signature

Date

Prev Page Complete

II. School of Graduation

School of Graduation:

Year:

Other School: Graduation Date (MO/DAY/YR): Continuing Education Course

State:

Year:

Title:

Administrator:

Additional Considerations: Request Left Handed Unit:

III. Anesthesia Training Verification

I am trained to Administer Local Anesthesia:

Yes

No

If yes, please select one of the options below:

The course I took was administered within the CRDTS Region. I understand that I must submit a certificate from that course, verifying I have had the appropriate educational and clinical training to administer anesthesia at the examination site. I also understand that if I am a recent graduate from one of the accredited dental hygiene schools within the CRDTS Region, or I am soon to graduate, my school may submit my name on a 'blanket' letter on official letterhead, along with other graduates, verifying my training.

I am not a present graduate or attending a school within the CRDTS Region. I must submit a certificate, or letter from my school or course on official letterhead verifying that I have had the appropriate educational and clinical training to administer anesthesia at the examination site.

IV. Retake Examination

Are you retaking this examination?

Yes

No

If you are not taking the entire exam or are retaking the exam, please specify which parts.

Written Exam

Clinical Exam

V. Examination Dates

Please select three choices in chronological order.

VI. Previous Examination Information

If you have taken the CRDTS Local Anesthesia Exam previously, or a Local Anesthesia Exam with another agency, please indicate the agency, site(s) and exam date(s) (MM/YY).

Previous Examination Clinical Sites(s)

Testing Agency

Previous Exam (Date - MM/YY)

VII. Limitation of Liability Agreement

1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
3. Volunteer Patients and Dental Assistants. As part of the examination, you must perform certain types of clinical procedures on volunteer patients. Volunteer patients must sign a "Treatment Consent Form" prior to any procedure. Dental candidates are permitted to use their own dental assistant(s) during the examinations, and they are required to supply both the volunteer patient(s) and dental assistant(s), if any, at their own expense. Dentists and dental hygienists (licensed or unlicensed), third or fourth year dental students, final year dental hygiene students, dental technicians and expanded duty auxiliaries (if providing services normally done by a dentist) may not act as chairside assistants during any CRDTS examination.
4. Limitation of Liability, Assumption of Risk, and Indemnity.

A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.

5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.

VIII. Candidate Signature

By checking this box the applicant acknowledges that s/he has read and understood the following and agrees to abide by all terms and conditions contained therein.
1. Application
2. Anesthesia Candidate Manual

I hereby state that I have read and understand Section V above: Disclosure, Limitation of Liability and Indemnity Agreement and agree to its terms.

These electronic signatures are legally binding and have the full validity and meaning as the applicant’s handwritten signature.

Electronic Signature

Date

Prev Page Complete

Complete Application

Current Address:	School of Graduation (year): Continuing Education Course: Taking Exam Exam(s): Previous Exams:
Hygiene: Taking Exam Exam(s): Previous Exams:	Restorative Auxiliary: Taking Exam Exam(s): Previous Exams:




Additional Considerations:


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Central Regional Dental Testing Service

Over 50 Years of Dental and Dental Hygiene Testing Excellence!

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